Ctrl+Click on Text to Go Directly to Section s2

Emergencies Table of Contents

(ctrl+click on text to go directly to section)

CLINICAL PROTOCOLS

Medical Emergencies...... 1

Emergency Equipment, Supplies & Medications...... 2

Medical Emergencies Protocol...... 3 Anaphylaxis...... 4 Dosages for Epinephrine Administered IM...... 6 Dosages for Diphenhydramine HCL (Benadryl®) Administered Orally...... 7 Dosages for Diphenhydramine HCL (Benadryl®) Administered IM...... 8 MEDICAL EMERGENCIES

LHDs should be prepared for medical emergencies, particularly, life-threatening drug reactions. Established procedures, adequate and properly maintained equipment, and appropriately trained staff are essential.

 Protocols for emergency care for anaphylactic reactions, and management of vasovagal reactions and syncope should be signed by a local physician and a copy kept with the emergency supplies.  If the LHD stocks an Automated External Defibrillator (AED) device, it must develop and maintain local policies on its use and maintenance.  LHD prepared for more extensive emergency measures should have a locally developed protocol in place to guide staff.  Emergency equipment, supplies, and medications should be maintained on a crash cart or emergency tray.  An inventory list is to be kept with the crash cart or emergency tray and monitored monthly according to an established schedule to ensure that they are not depleted or expired. Emergency supplies should be sealed when not in use.  All physicians, clinicians, and nurses should be certified in CPR.  All staff should be offered the opportunity to participate in CPR training.  At a minimum, all staff must know their role in an emergency situation.  All staff should have access to the Poison Control phone number, 1-800-222-1222, and it should be posted in a prominent place.

Page 2 of 8 Core Clinical Service Guide Section: Emergencies January 15, 2016 EMERGENCY EQUIPMENT, SUPPLIES, AND MEDICATIONS Inventory List* (When Equipment and Supplies are replaced, LHDs should order Latex-free.)

 AMBU bag – at least 1 Adult and 1 Pediatric unit (Latex-free), checked for physical integrity at least monthly and replaced per manufacturer’s recommendations.  One-way masks – at least 1 adult and 1 pediatric mask. latex-free, and at least one replacement piece for each mask  Sphygmomanometer, age appropriate, ex. pediatric, adult, extra-large – serviced according to manufacturer’s recommendations  Stethoscope  Flashlight and extra batteries  Oxygen tank with mask (serviced yearly and checked monthly)  Syringes and needles of various sizes, including filtered needles for use with ampoules (for the removals of minute particles of glass, filtered needles are not to be used for administration.)  Alcohol swabs or sponges  Gloves, latex-free  Aqueous epinephrine (1:1000); in either prefilled syringes, EpiPen® Auto-Injectors (0.3 mg) and EpiPen® Jr (0.15 mg) Auto-Injectors, or ampoules; at least 4 but more for medically isolated clinics). DO NOT BUY 30 mL vials of aqueous epinephrine.  Diphenhydramine hydrochloride (HCL) (Benadryl® elixir) Liquid (Each 5 mL contains 12.5 mg of Diphenhydramine HCL); Diphenhydramine hydrochloride (Benadryl® Injection) 50 mg/mL in ampoules, disposable syringes, or vials, (a minimum of 4)  Poison Control phone number 1-800-222-1222 Find Your Local Poison Center: http://www.aapcc.org/dnn/AAPCC/FindLocalPoisonCenters.aspx  Kentucky Regional Poison Center Medical Towers South, Suite 847 234 East Gray Street Louisville, KY 40202 Emergency Phone: (800) 222-1222 http://www.krpc.com/  Emergency equipment, supplies and medications inventory list with log of monthly reviews/inventory  Emergency protocols signed by a local physician

*A copy of the Emergency Equipment, Supplies, and Medications list is to be placed on the crash cart, emergency tray, or off-site emergency kits with a copy of the current signed protocols.

LHDs may develop modified equipment lists and modified emergency and anaphylactic shock protocols for off-site service or alternate service delivery sites. These should, at a minimum, include epinephrine and diphenhydramine hydrochloride, as well as access to a phone to summon emergency personnel (911).

Page 3 of 8 Core Clinical Service Guide Section: Emergencies January 15, 2016 MEDICAL EMERGENCIES PROTOCOL*

For various reasons in a LHD setting, a patient may complain of feeling “light headed”, “faint”, or actually “passing out”. This may be as simple as a reaction to certain sensory stimuli, real or perceived pain, or sudden changes in position or as severe as an acute medical condition, such as cardiac or other life threatening conditions.

Condition Intervention

Syncope/Vasovagal  ABC’s (Airway, Breathing, Circulation) Reaction  Place patient in supine position and loosen clothing. “light headed – fainting”  Elevate lower extremities 20–30 degrees. Response to patient is  Monitor and record BP, pulse and respirations. usually immediate when  Document all findings and actions in patient’s medical record. measures are taken.  Question patient after episode about feelings prior to syncope and whether this is an isolated event or “usual response” to certain stimuli.  Advise patient to report this to their physician or primary care provider for further investigation.

Suspected Severe, Acute  ABC’s Medical Condition  Call for staff assistance including cardiac arrest,  Maintain AIRWAY, provide CPR if necessary shock, hemorrhage, and/or o Place patient in supine position and loosen clothing. aspiratory difficulties o Monitor and record vital signs.  Call 911 or local Emergency Medical Services immediately (preferably have someone not involved in direct patient care make the call).

*Place a copy of this protocol on the crash cart, emergency tray with the Emergency Equipment, Supplies and Medications Inventory List and the Treatment of Anaphylactic Shock Protocol. Modified emergency and anaphylactic shock protocols may be developed locally for off-site service.

Page 4 of 8 Core Clinical Service Guide Section: Emergencies January 15, 2016 PROTOCOL FOR TREATMENT OF ANAPHYLAXIS *

Observation/ Condition Intervention (Mild and Moderate Reactions) Assessment MILD  Generalized  ABC’s. REACTION flush  Call 911 or local EMS STAT (Preferably have someone not (May rapidly  Red, itchy, eyes involved in direct patient care make the call). progress to a more severe  Itching at the  Place patient in supine position. reaction) injection site or  Monitor vital signs. at other body  GIVE OXYGEN BY MASK, if any respiratory symptoms are sites present  Localized to o Special instructions** for O2 administration, if generalized given urticaria (hives) (O2 flow rate, lpm) ______ Vomiting, abdominal pain  FIRST-LINE TREATMENT: GIVE AGE AND WEIGHT APPROPRIATE DOSES OF EPINEPHRINE, intramuscularly, preferably in the anterolateral thigh (See Table 1). Repeat every MODERATE  5–15 minutes, up to 3 doses, depending on patient’s response REACTION Mild to moderate  SECONDARY TREATMENT: As an adjunct to wheezing epinephrine, give weight or age appropriate doses of  Coughing diphenhydramine HCL orally or intramuscularly (See Table 2 or  Table 3). DO NOT GIVE diphenhydramine HCL to infants Complains of aged less than 7 months generalized itching,  Continue to observe for change in symptoms (lessening or itching throat worsening)   Maintain accurate emergency flow sheet showing: Generalized urticaria o Date o Time of occurrence (hives) o Vital Signs  o Medication(s) (time, dosage, response,, name of Swelling of lips, face, healthcare personnel who administered the medication) tongue, eyelids, o Immediate therapy o Disposition of patient (transfer for further emergency hands, feet, or care ASAP) genitalia.  Send summary of emergency treatment with patient with  written assessment of patient’s condition at time of transfer. Vomiting, diarrhea,  Document all measures taken in patient’s medical record and and/or abdominal place allergy label on front of patient’s medical record. Advise pain patient (parent) about the drug or trigger that caused reaction.  Advise patient (parent) to report reaction to their physician or primary care provider.

* Place a copy of this protocol on the crash cart, emergency tray with the Emergency Equipment, Supplies and Medications Inventory List and Medical Emergencies Protocol. Modified emergency and anaphylactic shock protocols may be developed locally for off-site service.

**Oxygen flow rates, particularly for infants and children, depend upon the equipment available. LHDs should consult the equipment manufacturer for relevant information and annotate protocols with the appropriate oxygen flow rates. http://www.redcross.org/images/MEDIA_CustomProductCatalog/m3240082_AdministeringEmergencyOxygenF actandSkill.pdf

Page 5 of 8 Core Clinical Service Guide Section: Emergencies January 15, 2016 PROTOCOL FOR TREATMENT OF ANAPHYLAXIS* (Continued) Observation/ Condition Intervention (Severe Reaction) Assessment SEVERE  Anxiety  ABC’s REACTION  Shortness of Breath  Call 911 or local EMS STAT (Preferably have someone not  Severe Wheezing involved in direct patient care make the call).   Place patient in supine position. Progressive swelling  Elevate legs and loosen clothing. of lips, face,  Elevate head, if breathing is difficult. tongue, eyelids,  Monitor pulse and respiration, mental status q 1–2 minutes. hands, feet, or  Monitor BP – age 3 years and up genitalia.  GIVE OXYGEN BY MASK (Maintain airway – hypoxia can  result from hypotension and upper airway edema). Progressive o Special Instructions** for O2 administration, if given generalized (O2 flow rate, lpm) ______urticaria (hives)  FIRST-LINE TREATMENT: GIVE AGE AND WEIGHT  Restlessness APPROPRIATE DOSES OF EPINEPHRINE, intramuscularly,  Headache preferably in the anterolateral thigh (See Table 1). Repeat every  Vomiting 5–15 minutes, up to 3 doses, depending on patient’s response  Incontinence  SECONDARY TREATMENT: As an adjunct to epinephrine, give  Cyanosis weight or age appropriate doses of diphenhydramine HCL  Confusion intramuscularly (See Table 3). DO NOT GIVE diphenhydramine  Weak rapid pulse HCL to infants aged less than 7 months  Hypotension  Perform cardiopulmonary resuscitation, if necessary  Shock  Maintain accurate emergency flow sheet showing:  Unconsciousness o Date o Time of occurrence o Vital Signs o Medication(s) (time, dosage, response,, name of healthcare personnel who administered the medication) o Immediate therapy o Disposition of patient (transfer for further emergency care ASAP)  Send summary of emergency treatment with patient with written assessment of patient’s condition at time of transfer.  Document all measures taken in patient’s medical record and place allergy label on front of patient’s medical record.

** Oxygen flow rates, particularly for infants and children, depend upon the equipment available. LHDs should consult the equipment manufacturer for relevant information and annotate protocols with the appropriate oxygen flow rates. http://www.redcross.org/images/MEDIA_CustomProductCatalog/m3240082_AdministeringEmergencyOxygenFact andSkill.pdf

Page 6 of 8 Core Clinical Service Guide Section: Emergencies January 15, 2016 Table 1: Dosages for Epinephrine Administered Intramuscularly The recommended dose of epinephrine is 0.01 mg/kg body weight. Repeat every 5–15 min. up to 3 doses, depending on patient’s response.

Epinephrine Dose:

Range of Weight Range of Weight 1 mg/mL injectable Age Group: Epinephrine (Pounds)* (Kilograms)* (1:1000 dilution) Auto-Injector intramuscular (IM) (EpiPen) Minimum dose: 0.05 mL

1 - 6 months 9 - 19 lbs 4 - 8.5 kg 0.05 mL (or mg) Off label

7 - 36 months 20 - 32 lbs 9 - 14.5 kg 0.1 mL (or mg) Off label Infants and 37 - 59 months 33 - 39 lbs 15 - 17.5 kg 0.15 mL (or mg) 0.15 mg Children 5 - 7 years 40 - 56 lbs 18 - 25.5 kg 0.2 - 0.25 mL (or mg) 0.15 mg

8 - 10 years 57 - 76 lbs 26 - 34.5 kg 0.25 - 0.3 mL† (or mg) 0.15 mg or 0.3 mg

11 - 12 years 77 - 99 lbs 35 - 45 kg 0.35 - 0.4 mL (or mg) 0.3 mg Teens 13 - 18 years 100+ lbs 46+ kg 0.5 mL (or mg)‡ 0.3 mg

Adults 19 years & older 100+ lbs 46+ kg 0.5 mL (or mg)‡ 0.3 mg Note: If body weight is known, then dosing by weight is preferred. If weight is not known or readily available, dosing by age is appropriate. *Rounded weight for infants, children, and teens at the 50th percentile for each age range † Maximum dose for children ‡ Maximum dose for teens and adults

Page 7 of 8 Core Clinical Service Guide Section: Emergencies January 15, 2016 Table 2: Dosages for Diphenhydramine HCL (Benadryl®) Administered Orally The recommended dose of diphenhydramine HCL is 1 – 2 mg/kg body weight. Benadryl Dose, given orally: Range of Weight Range of Weight Age Group: (Pounds)* (Kilograms)* 12.5 mg/5 mL liquid, 12.5 mg/5 mL liquid Dose, orally, mL

1 - 6 months DO NOT GIVE TO THIS AGE GROUP

7 - 36 months 20 - 32 lbs 9 - 14.5 kg 10 mg – 20 mg 4 mL – 8 mL Infants and 37 - 59 months 33 - 39 lbs 15 - 17.5 kg 15 mg – 30 mg 6 mL – 12 mL Children 5 - 7 years 40 - 56 lbs 18 - 25.5 kg 20 mg – 30 mg 8 mL – 12 mL

8 - 12 years 57 - 99 lbs 26 - 45 kg 30 mg† 12 mL†

Teens 13 - 18 years 100+ lbs 46+ kg 50 mg‡ 20 mL‡

Adults 19 years & older 100+ lbs 46+ kg 50 mg‡ 20 mL‡ Note: If body weight is known, then dosing by weight is preferred. If weight is not known or readily available, dosing by age is appropriate. *Rounded weight for infants, children, and teens at the 50th percentile for each age range † Maximum dose for children ‡ Maximum dose for teens and adults

Page 8 of 8 Core Clinical Service Guide Section: Emergencies January 15, 2016 Table 3: Dosages for Diphenhydramine HCL (Benadryl®) Administered Intramuscularly The recommended dose of diphenhydramine HCL is 1 – 2 mg/kg body weight. Benadryl Dose, given by injection: Range of Weight Range of Weight Age Group: 50 mg/mL injectable (Pounds)* (Kilograms)* 50 mg/mL injectable Volume injected IM IM, mL

1 - 6 months DO NOT ADMINISTER TO THIS AGE GROUP

7 - 36 months 20 - 32 lbs 9 - 14.5 kg 10 mg – 20 mg 0.2 mL – 0.4 mL Infants and 37 - 59 months 33 - 39 lbs 15 - 17.5 kg 15 mg – 30 mg 0.3 mL – 0.6 mL Children 5 - 7 years 40 - 56 lbs 18 - 25.5 kg 20 mg – 30 mg 0.4 mL – 0.6 mL

8 - 12 years 57 - 99 lbs 26 - 45 kg 30 mg† 0.6 mL†

Teens 13 - 18 years 100+ lbs 46+ kg 50 mg‡ 1 mL‡

Adults 19 years & older 100+ lbs 46+ kg 50 mg‡ 1 mL‡ Note: If body weight is known, then dosing by weight is preferred. If weight is not known or readily available, dosing by age is appropriate. *Rounded weight for infants, children, and teens at the 50th percentile for each age range † Maximum dose for children ‡ Maximum dose for teens and adults

Page 9 of 8 Core Clinical Service Guide Section: Emergencies January 15, 2016